May 29, 2017

The editor-in-chief of one of my
favorite health news sources, Kaiser Health News, recently published her first
book—for over twenty years she has been a journalist at the New York Times—and
it’s an important one. An American Sickness: How Healthcare Became Big Business
and How You Can Take it Back, by Elisabeth Rosenthal, is a powerful if somewhat monotonous
recounting of the evils of American health care. But it only seeks to explain
one weakness of contemporary American medicine, albeit an important one: it
costs too much. Or, more accurately, prices are too high. As Uwe Reinhardt put
it years ago, “it’s the prices, stupid.”

Understanding the behavior of
physicians, hospitals, drug companies, health insurers, and device
manufacturers, as this book seeks to do, is critical if we are to change the
system. The problem that they create, however, isn’t just that health care
costs consumers too much; it’s also that the quality lags behind what is
achievable—is evidenced by the poor standing of the US compared to other
developed countries. Failing to consider both quality and cost is
regrettable—we might, after all, be willing to tolerate the enrichment of drug
company shareholders if what we got in return was an excellent, if pricey,
product.

The
litany of shenanigans by big business may be familiar to many readers, but Rosenthal's comprehensive and detailed accounting is impressive and compelling. Consider the
first chapter on “the age of insurance.” The book recounts the story of how
the same treatment costs orders of magnitude more--$100,000 vs $19,000 per
medication infusion for a drug given monthly—when administered at NYU’s Langone
Medical Center than when provided at another nearby facility. For the patient,
whose treatment was covered by insurance, it didn’t much matter over the short
run. But for the system as a whole, and ultimately for all patients through
higher insurance premiums, it did matter. And the reason for the discrepancy is
that NYU negotiated a better deal with third party payers than did the
competition. What Rosenthal outlines but does not emphasize is that more
powerful hospital systems and physician researchers interact with (some might
say collude with) health insurance companies to produce this result. She
explains that because of an arrangement with the NYU researcher who was largely
responsible for creating the drug, NYU derived profit if total sales of the
drug exceed a particular threshold. By negotiating a very high payment for the
drug from the insurer, NYU is likely to exceed the threshold and cash in. So
it’s not just the motivations of physicians, hospitals, and insurance companies acting separately that impact the health care system; it’s the way all of these forces
work together that is crucial to achieving the end result.

Rosenthal presents one disturbing case after another. There’s the way hospitals
and physicians game the system to assure that patients essentially have to use out-of-network
providers when their insurance company will only cover in-network providers,
forcing patients to shoulder what can be enormous costs. There’s the notorious
“facility fee” that enables hospitals to charge insurers vastly more for a
simple procedure such as injecting anti-inflammatory medication into a joint if
it is done in an outpatient clinic than if it is done in a private office. What
she neglects to explain is the way the system conspires to provide what is
often inferior medical care to patients. Maybe this is more egregious with
older patients than younger ones, and her focus is overwhelmingly people who
aren’t enrolled in Medicare: either those with private insurance or no
insurance at all. The facility fee example, for instance, doesn’t just mean
higher costs. For a frail older person to get to a hospital clinic may mean
going by car, negotiating a confusing parking garage, and walking a
considerable distance from the garage to the office, none of which is so easy
if you’re 85, have severe arthritis (the reason for going for the joint
injection in the first place), and maybe have a little cognitive impairment to
boot. The enthusiasm for high tech procedures, driven in part by the
manufacturers of the devices used in the procedures, doesn’t merely drive up
costs: for vulnerable, older individuals, such technological intervention may
cause more harm than good. The anesthesia may result in confusion and the
hospital stay in functional decline—quite apart from the effect on the cost of
medical care.

Alas, the fixes the author proposes, the part of the book devoted to taking "health care back" from big business, aren’t going to fix the system. She calls
for creative insurance plan design, for example plans that cover
“essential” treatment fully and levy co-pays for “semi-elective” treatment.
That’s much like what the ACA does when it requires full coverage for preventive services
such as a screening colonoscopy, but allows the same colonoscopy to be billed
in full (if the patient has a high deductible health plan) if the procedure is ordered to remove a
cancerous polyp. Maybe that’s a good idea, although it leads to some bizarre
incentives—better to get that polyp removed at the end of the plan year, when
you might already have burned through your deductible, than at the beginning of
the year, when the growth might be more curable; better to say nothing to your doctor
about the blood you’ve noticed in your stools and just have a “screening test”
than to mention the blood and undergo the procedure to treat a “disease.” But
whether or not “benefit redesign” is a good idea—and one of the last major
benefit redesign ideas wasn't so thrilling, it was those very high deductible health plans that are
conquering the market—it’s not going to help patients now. Even the suggestions
that could, in principle, help right away, such as “demanding price
transparency” when getting an MRI, are a bit pie-in-the sky. You’re in the
doctor’s office and s/he wants you to get a scan right away. You’re supposed to
get a list of 5 centers that do MRIs and compare their prices? Really? What
about quality? What about accessibility of the image to your physician? What about transportation to these other sites?

An
American Sickness goes a long way to uncovering the workings of the health
system and for that it is to be lauded. It is extensively and for the most part
carefully researched, though there are errors. Rosenthal says pharmacists should be
able to prescribe birth control pills because they all have PhDs and shouldn’t
just be relegated to counting pills. Maybe they should be able to prescribe
birth control pills, but most pharmacists have a BPharm (a bachelor’s degree),
not a PhD. She says the website GoodRx allows comparison of prices for
prescription drugs only for Medicare patients. Maybe that was once true, but it
is no longer. But read this book for the insight it may give you on how the design of
the system affects outcomes. We will need to build on that scaffolding to investigate the full
range of systemic consequences—for quality as well as cost of health care, and
to engage in meaningful reform.

May 21, 2017

This month, the Commonwealth Fund, a private foundation that supports independent research on the health care system, released a report on just how much Medicare beneficiaries pay out of
pocket for health care. The news is sobering: on average, they spend $3,024 and
that doesn’t include what they pay for premiums.

I’m not sure why premiums are
considered separately, but they’re pricey, too. While Medicare part A (hospital
coverage) is free for almost everyone over age 65, Medicare part B (doctors’
fees, outpatient care, and lab tests) costs $134 per person per
month. That is, if you’re single and earned less than $85,000 in 2015, or
married and jointly earned no more than $170,000. After those thresholds, the
premium rises steeply, first to $187 per person per month (for joint incomes of
up to $214,000) and then on up to a maximum of $429 for the most affluent. Then
there’s part D for medications. The average monthly cost for a drug plan this
year is $42 per person. And finally, there are Medigap plans if people want
coverage for their deductibles and co-pays—the national average for those
plans is $183 per person per month.

Looking at averages is not
terribly enlightening, but fortunately, the report delves far deeper. It turns
out that among people with three or more
chronic medical conditions (30 million of the 56 million people enrolled in
Medicare), 29 percent spent at least 20 percent of their incomes on
out-of-pocket medical care plus premiums. Among the nearly 14 million people
with a serious physical and/or cognitive impairment, 38 percent spent at least
20 percent of their incomes on out-of-pocket medical care plus premiums. The
poorest people are particularly hard hit: among the 17 million people with
three or more chronic conditions or functional limitations whose incomes is
less than 200 percent of the federal poverty level, 42 percent spend at least
20 percent on medical expenses.

After reading the report, I
had two questions. First, how do Medicare beneficiaries in Medicare Advantage
plans fare compared to those in conventional, fee-for-service Medicare? They
pay part B premiums plus a part C premium—which is instead of Part D
but also includes more comprehensive coverage with fewer co-pays and
deductibles. The actual part C premiums vary tremendously, both within a given insurance company (in Massachusetts, for example, Blue Cross offers 6 different Medicare
Advantage plans, with monthly premiums ranging from 0 to $295 per person; a middle-of-the-road plan costs $79 per month) and across companies. My suspicion is that people with
multiple chronic conditions or functional impairment are less likely than their
healthier peers to choose Medicare Advantage—but that they would have lower
out-of-pocket costs if they did. Someone should do the analysis.

Second, how would the
ACA-Repeal-and-Replace bill passed by the House of Representatives affect
Medicare? The answer seems to be that it would only affect it indirectly, mainly
by cutting federal spending on Medicaid by $880 billion over ten years. This would
profoundly impact the 11 million people who are currently enrolled in both
Medicare and Medicaid. It would also worsen the overall solvency of the
Medicare program. The ACA levies an extra payroll tax of 0.9 percent on
individuals earning over $200,000 a year ($250,000 for couples), a tax that is
due to expire in 2018. The new bill would end the payroll tax a year early—thus
ensuring that the Medicare trust fund, which pays for part A, will run out of
money before 2025.

The take home message? Find
out if there’s a good Medicare Advantage program available to you and what it
costs. It just might be a better deal than regular Medicare. And lobby your
senators to make sure that any new variant of repeal-and-replace doesn’t gut
Medicaid or bankrupt Medicare.

May 15, 2017

In a
provocative piece in the NY Times last week, science writer Gina Kolata suggests that the long term care insurance industry may be in a “death spiral.”
The culprit, she argues, is genetic testing, which got a boost last month when
the FDA approved testing by the company 23andMe. Previously best known for
providing genealogical information to those who send in a saliva sample and a $99
fee, the personal genomics company is now authorized to provide information
about genetic risk factors as well—for only an additional $26.

One of the
ten conditions about which companies may offer information is Alzheimer’s
disease. And perhaps the best established genetic risk factor for late-onset
Alzheimer’s disease (sometimes called LOAD) is apoE. A gene that codes for a
protein involved in cholesterol metabolism, apoE comes in three varieties,
prosaically named apoE2, apoE3, and apoE4. Everyone has two copies of the apoE
gene, so there are six possible genotypes, of which the most common are E2/E2, E3/E3,
E4/E4, E2/E3, and E3/E4. The majority of people (63 percent, in one study of the distribution of the allele in 9 different populations) are E3/E3.

But while
there is no way to definitively predict who will develop Alzheimer’s disease,
fully 40 percent of people who develop LOAD are among the 25-30 percent of
people who carry the e4 variant of the gene. And roughly half the residents of
nursing homes have Alzheimer’s disease. As a result, according to spokesmen
from the industry, a growing number of people are seeking testing from 23andMe
to see if they have the e4 gene. If they have it, they buy long term care
insurance. If they don’t, they take their chances.

If this
trend continues—and as of 2017, 2 million people have obtained the direct to
consumer genetic analyses---the pool of people buying long term care insurance
could be heavily weighted towards those who actually will develop the disease.
The health insurance industry, however, as consumers are perhaps finally coming
to understand in the ongoing Obamacare wars, depends on pooled risk; it only
works if the people who buy insurance include some people who will get sick and
others who won’t.

The reason
the direct-to-consumer marketing of genetic information potentially spells doom
for the long term care industry is that Americans are protected by the Genetic
Information Nondiscrimination Privacy Act, which prevents insurers from
requiring gene tests or using the results of genetic testing in coverage
decisions. That means that ordinary people, without any physician input, can
find out if they are at high risk, they can make decisions about buying
coverage based on that assessment—and the insurance companies are powerless to
intervene. If most of the people who are destined to get Alzheimer’s disease
end up with insurance, the insurance company will end up paying out a lot more
than they originally anticipated—leading to enormous increases in the rates or
bankruptcy of the industry.

Now there
are plenty of other reasons that the long term care insurance industry may
collapse, and a good number of pre-existing reasons why it’s a poorly designed
program. The amount of money it actually provides people is rarely enough to
cover their actual costs, whether of home or institutional care. There are many
barriers in the way of people using their benefits—for example, many policies
require three months of disability before they kick in, which may be three
months too long, especially if they are only going to be in a nursing home for
three months. And Medicaid is currently available as a back up to pay for
institutional care, provided people have “spent down” their personal savings,
so the value of long term care insurance derives from its ability to shelter
assets.

Analyzing
the value of long term care insurance is a conversation for another blog post.
But the point I want to make today is that before you rush out and get tested
for Apo E, you should be aware of the limited predictive value of the test. While
the likelihood of getting LOAD if you are one of the 2.6 percent of the
population who have two copies of E4 is 91 percent, the likelihood of getting
LOAD if you are one of the 22 percent of the population with one copy of the E4
allele falls to 47 percent. And if you are one of the 76 percent of the
population with no E4 alleles, you still have a 20 percent of getting
Alzheimer’s. Because the poor “negative predictive value”—because even with a
negative test, you have a substantial risk of getting the disorder—physicians
and organizations such as the Alzheimer’s Association have for years
recommended against routine Apo E screening.

Interestingly,
Apo E determination has been available to Europeans as a direct to consumer
test for years. A study to find out what the short- and long-term psychological consequences were for patients with a positive test. Though the study only
looked at people who requested testing, it found that there were no significant
adverse consequences of getting bad news. So fear that you will become anxious
or depressed is probably not grounds for resisting the impulse to be tested for
Apo E4. But you
should remember that it’s just a risk factor—and one over which you have no
control—and plenty of people who test negative will still develop Alzheimer’s
disease.

May 07, 2017

In
the sixties, physicians routinely prescribed bed rest for patients who had
suffered a heart attack. Then along came the recognition that bed rest led to
clot formation in the lower extremities, clots that sometimes broke off and
traveled to the lungs, causing potentially life-threatening pulmonary emboli.
Bed rest also led to deconditioning—when patients finally were allowed to get
up, they found they were often weak and wobbly. And so bed rest was out and
early mobilization was in. But now, concurrent with a vigorous attempt to
prevent falls among older hospitalized patients, bed rest is back in—and with
more complications than ever, as reported in a thoughtful article in JAMA Internal Medicine last week.

In
2008, in response to the observation that “injurious falls” were responsible
for increased hospital costs and were clearly bad for patients, the Centers for
Medicare and Medicaid Services introduced a program incentivizing hospitals to
prevent falls. Currently, a fall resulting in significant injury (such as a
fracture) is one of eight hospital-acquired conditions that collectively determine
whether hospitals will be penalized for poor performance. To address the CMS
initiative, hospitals introduced a variety of techniques designed to keep older
patients from falling such as bed alarms and “fall risk” signs on the door.
According to Growdon and colleagues, the result has been a “national epidemic
of immobility among hospitalized older adults.”

Paradoxically,
the means used by hospitals to prevent falls don’t work. Bed (and chair) alarms
are ineffective—which is not entirely surprising, as by the time a nurse
responds to the buzzer indicating the patient has gotten out of bed (or chair),
the person is probably already on the floor. Even a multi-prong study from
Australia using a variety of different approaches simultaneously was
unsuccessful.

But
all those bed alarms and signs on the door do achieve something, and that’s to
keep patients at bed rest. And just as bed rest was bad for heart attack
patients in the sixties, it’s bad for older patients today. Bed rest promotes
the development of confusion (delirium) and worsens mobility, so when patients
finally do get out of bed, either late in their hospital stay or after they get
home, they are more likely to fall.

Growdon,
a resident in internal medicine at a major Boston teaching hospital, and his
colleagues at a VA Hospital in Florida and at Hebrew Senior Life, a teaching
nursing home, are rightfully indignant. They advocate promoting mobility rather
than penalizing falls, arguing that “although hospital falls can lead to harm,
treating them as ‘never events’ has led to over implementation of measures with
little efficacy for falls [prevention] yet profound contribution to
immobility.” They are, no doubt, correct. But why? Why should an incentive
program based on outcomes lead to the adoption of a strategy that does not lead
to the desired outcome?

If
CMS had used a process measure, if it had offered extra payments to
hospitals that introduced fall prevention programs, I wouldn't have been surprised that it resulted
in hospitals adopting programs for the sake of having something, regardless of
efficacy. But instead it opted to penalize hospitals for performing poorly, which should by rights have led to hospitals choosing to take steps that made a difference. What is it about the culture
of hospitals or the leadership of hospital CEOs or the knowledge base of
physicians and nurses that lets them make such irrational choices?

I
wish I knew the answer. In the meantime, perhaps CMS would do well to offer
carrots rather than sticks, and to be specific about the kind of carrots that
it likes the most. If programs that promote mobility work, directives to get patients out of bed early and to consult physical therapy—both to prevent falls
and to maintain function—then it’s those specific programs it should endorse
and pay for.